The Laryngoscope
C 2015 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Systematic Review
Contemporary Applications of Frontal Sinus Trephination:
A Systematic Review of the Literature
Alpen B. Patel, MD; Rachel B. Cain, MD; Devyani Lal, MD
Our objective was to perform a systematic review of the literature on contemporary indications and outcomes for frontal
sinus trephination and present an illustrative case of an endoscopically assisted repair of a subcutaneous frontal sinus fistula
by trephination technique. PubMed and Ovid databases were used as data sources. A systematic review of the English literature was completed to review reports of frontal trephination from 1980 to 2014. Articles meeting inclusion criteria for
inflammatory and noninflammatory indications were reviewed. Articles were systematically reviewed and graded by
evidence-based medicine level. An illustrative case from our institution is then presented. The systematic review identified
2,621 published studies. Thirty-eight studies were identified for inclusion. The indications, techniques, outcomes, safety, and
complications were reviewed for noninflammatory and inflammatory conditions. There were 32 retrospective case series,
reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one metaanalysis (level 2). Due to the heterogeneity of study cases and inclusion criteria, a meta-analysis was not feasible. We also
present a novel closure of an anterior skull base defect resulting in a subcutaneous fistula with use of a frontal trephination
approach. The frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. This approach provides access for instrumentation for hard-to-reach frontal
sinus disease either purely through a trephination approach or as a supplementation to the transnasal endoscopic approach.
Evidence supporting frontal sinus trephination is of levels 2, 3, and 4.
Key Words: Endoscopic sinus surgery, frontal sinus, trephination, minitrephination, external approach, fistula.
Level of Evidence: NA
Laryngoscope, 125:2046–2053, 2015
INTRODUCTION
Indications for endoscopic surgical approaches to
the frontal sinus have expanded with increasing experience with endoscopic techniques. The frontal trephination technique is a very useful adjunct to reach far
lateral and superior disease in frontal sinus surgery,
when endoscopic access alone is not sufficient.1–4 The
use of the combined endoscopic-trephination approach
can potentially supplement the need for a conventional
external approach such as the osteoplastic flap technique.5,6 Conventionally, surgeons chose between traditional open approaches (osteoplastic flap, frontal
trephination) or purely endoscopic approaches (endoscopic frontal sinusotomy, endoscopic modified Lothrop).6,7 However, the combination of trephination with
endoscopic techniques is increasingly being utilized for
From the Department of Otolaryngology–Head and Neck Surgery,
Mayo Clinic, Phoenix, Arizona, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
January 21, 2015.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Devyani Lal, MD, Assistant Professor of
Otolaryngology, Department of Otolaryngology, Mayo Clinic, 5777 E.
Mayo Blvd., Phoenix, AZ 85054. E-mail: [email protected]
DOI: 10.1002/lary.25206
Laryngoscope 125: September 2015
2046
frontal sinus surgery for rhinosinusitis and associated
pathology.5–8
This article focuses on use of frontal sinus trephination performed for both inflammatory and noninflammatory indications. Historically, trephination has been used
to emergently treat acute frontal sinusitis or complications related to acute frontal sinusitis.9,10 However, a
minitrephination can also provide an additional porthole
for endoscopic visualization and instrumentation to treat
myriad pathologies in the frontal sinus.7 Simultaneous
insertion of the endoscope and surgical instruments can
be performed through a trephination, augmenting in
some cases, access through the transnasal endoscopic
approach.5,6
Endoscopic frontal trephination is a useful adjunctive procedure for frontal sinus surgery with minimal
morbidity with many contemporary indications.1–6 Our
goal was to highlight the versatility of the frontal trephination approach through our case report and through a
systematic literature review.
We performed a systematic literature review to
study the indications for and outcomes of frontal sinus
trephination used for inflammatory and noninflammatory indications in today’s contemporary era of endoscopic sinus surgery. We also describe repair of an aircontaining subcutaneous fistula from a breach of the
frontal roof–posterior wall junction using a purely
Patel et al.: Applications of Frontal Trephination
TABLE I.
Studies by Level of Evidence.
Level
No. of Studies
Type of Study
1
0
NA
2
3
1
5
Meta-analysis
Prospective, systematic review
4
32
Retrospective case series
5
0
Expert opinion
NA 5 not available.
frontal trephination approach through a brow incision.
To our knowledge, there has not been a similar report of
a case, or a critical systematic evaluation of the clinical
outcomes of endoscopic frontal trephination for both
inflammatory and noninflammatory diseases.
METHODS
An independent review of the literature was completed by
two authors. PubMed (www.ncbi.nlm.nih.gov/pubmed/) and
Ovid databases were searched with relevant terms, which
included the following: “trephination,” “mini-trephination,”
“frontal sinus,” “combined endoscopic and mini-trephination,”
“sinus fistula,” “craniotomy fistula,” “subcutaneous fistula,” and
“external approach.” A comprehensive review of the English literature was carried out with review of articles from 1980 to
2014. Duplicate articles were excluded. Our inclusion criteria
included studies related to noninflammatory or inflammatory
causes for surgical intervention via frontal trephination. Studies
consisted of a meta-analysis, review articles, systematic
reviews, and case reports. Included studies analyzed the procedure, indications, outcomes, and complications. Due to the heterogeneity of study cases, a meta-analysis was not feasible. This
study was deemed exempt by the Institutional Research Board,
Mayo Clinic, Phoenix, Arizona.
RESULTS
Systematic Review
The systematic review identified 2,621 studies published between 1980 and 2014. Careful review of the
full-length articles identified 38 studies reporting sufficient data deemed appropriate for inclusion in the
analysis.
Each article was then reviewed and graded on level
of evidence as ranging from level 1 (highest) to level 5
(Oxford Center for Evidence-Based Medicine; http://
www.cebm.net/index.asp). There were 32 retrospective
case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level
3), and one meta-analysis (level 2). The 38 studies were
analyzed for indications and outcomes for frontal trephination, safety, techniques, and complications of the
procedure.
Of the 38 studies included for review (Table I), all
articles were evidence-based medicine (EBM) levels 2, 3,
or 4. Thirty-three articles were reviews describing the
indications and outcomes for frontal sinus trephination.
One article was a meta-analysis of level 2 evidence. Five
of these articles were of level 3 evidence, one of which
was a prospective trial. Three of these articles included
discussion of complications. The remaining five articles
focused solely on the complications (two articles) and
aspects of safety surrounding the procedure (three
articles).
Indications—noninflammatory disease (EBM
levels 3, 4). Twenty-three studies, all of level 3 or level
4 evidence, discussed the role of frontal sinus trephination and the rationale for its use for noninflammatory
disease (Table II). Fifteen studies discuss specific indications for noninflammatory pathology, whereas eight
studies serve as reviews regarding the use and technique of frontal sinus trephination. If indications for
noninflammatory and inflammatory pathology are both
present within the same study, the inflammatory indications will be discussed later in this article.
Seiberling et al., Sieden and el Hefny, Busch, and
Batra et al. discuss the role of frontal sinus trephination
for removal of osteomas.5,11–13 Busch provided the initial
description of osteoma in 1992.13 In these four studies,
14 cases of complete osteoma removal have been
described, one case via external frontal sinus trephination approach alone, and 13 patients using frontal trephination as adjunct to endoscopic sinus surgery via an
“above and below” approach.5,11–13 Senior and Lanza
affirm this in their review describing trephination for
benign lesions in the frontal sinus.14 Zacharek et al. and
Batra et al. described the removal of fibrous dysplasia in
four patients through trephination.4,5 Batra et al., Sautter et al., Cohen and Wang, Yoon et al., and Walgama
et al. have all described removal of inverted papilloma
through trephination procedures in a total of 14
patients.5,7,15–17 Batra et al. has also described frontal
trephination for the treatment of one patient with
TABLE II.
Indications for Noninflammatory Disease.
Indication
Patients
First Author, Year
Fibrous dysplasia/osteoma
Inverted papilloma
19
14
Seiberling, 20092; Zacharek, 20064; Batra, 20055; Seiden, 199512; Busch, 199213
Batra, 20055; Cohen, 200716; Yoon, 200917; Sautter, 200715; Walgama, 20127
CSF leaks
14
Crozier, 201319; Purkey, 200920; Das, 201121
Posterior table fracture
Meningioma
2
2
Chaaban, 201223; Koento, 201224; Jatana, 200822
Kabil, 200618
Pneumocephalus
1
Batra, 20055
CSF 5 cerebrospinal fluid.
Laryngoscope 125: September 2015
Patel et al.: Applications of Frontal Trephination
2047
TABLE III.
Indications for Inflammatory Disease.
Indication
Patients
First Author, Year
Narrow frontal recess, severe edema, severe polyps,
obstructing frontal cells
163
Seiberling, 20092
Acute frontal sinusitis/chronic frontal sinusitis
86
Mucoceles, frontal sinusitis
38
Cohen, 200716; Gallagher, 19999; Gerber, 199327; Fry,
198026; Benoit, 200129
Batra, 20055; Courson, 20148
Mucoceles, type 4 frontal cells, frontal recess stenosis
or ossification
10
Zacharek, 20064
Chronic frontal sinusitis, frontal bone osteomyelitis
Pediatric frontal sinusitis
14
2
Hahn, 20096
McIntosh, 200728
Type 4 frontal cell
1
Maeso, 20093
Mucocele
1
Cho, 201025
pneumocephalus after craniectomy.5 Kabil presented
excision of two meningiomas through trephination.18
Crozier et al. and Purkey et al. describe the repair of
cerebrospinal fluid (CSF) leak resulting from noninflammatory causes through a sole trephination approach in
five patients.19,20 Das and Balasubramanian published
the concomitant use of endoscopic frontal sinusotomy
and access holes drilled through the anterior frontal
sinuses in nine patients.21 Lastly, posterior table fracture repair in one patient was described retrospectively
by Jatana et al., and one patient was reviewed through
a prospective trial by Chaaban et al.22,23 Koento further
supports anterior table and posterior table fractures
repair through frontal sinus trephinations.24 Mucoceles
were not included in this section, as all studies did not
discuss whether these were secondary to noninflammatory pathology. The remainder of the review articles
focused on the description and use of frontal sinus trephination, often as an adjunctive procedure, in challenging
frontal sinus pathology.
Indications—inflammatory disease (EBM levels
2, 3, 4). Frontal sinus trephination has been discussed
for inflammatory disease in 10 additional studies (Table
III). Three studies described earlier (Zacharek et al.,
Batra et al., and Cohen and Wang) describe indications
for both noninflammatory and inflammatory disease.4,5,16 All studies are of levels 2, 3, or 4 evidence.
Seiberling et al. provide the largest series, with 163
patients with indications for narrow frontal recess,
severe edema/polyps, obstructing frontal cells (type 3/
type 4 frontoethmoidal cells and intersinus septum
cell).2 Courson et al. provide a meta-analysis reviewing
the contemporary management of frontal sinus mucoceles via an external or combined approach. Twenty-one
patients
underwent
external-only
or
combined
approach.8 Zacharek et al. additionally described indications for inflammatory disease in 10 patients for superiorly or laterally based mucoceles (three patients), type 4
frontal cells (three patients), and frontal recess stenosis
or ossification (four patients).4 Batra et al. describe a
combined approach for mucoceles (15 patients) and frontal sinusitis (two patients).5 Maeso et al. present a case
report of trephination for frontal sinus type 4 cell disease where a combined approach was used.3 Cho et al.
Laryngoscope 125: September 2015
2048
describe a case report for treatment of a frontal sinus
mucocele.25 Gallagher and Gross (16 patients), Fry et al.
(16 patients), Cohen and Wang (12 patients), and Gerber
et al. (two patients) describe the use of frontal trephination for acute or chronic frontal sinusitis.9,16,26,27 McIntosh and Mahadevan present two cases of trephination
approach for pediatric frontal sinusitis.28 Hahn et al.
describe trephination use for chronic frontal sinusitis (11
patients) and frontal bone osteomyelitis (three
patients).6 Benoit and Duncavage reported on combined
external and endoscopic frontal sinusotomy with stent
placement in 40 patients with chronic frontal sinusitis.29
Outcomes (EBM levels 2, 3, 4). All studies demonstrating outcome measures were of level 2, 3, or 4 evidence. There was no heterogeneity with outcomes
reported, including frontal sinus patency (Table IV). If
outcomes were present in the studies, they have been
reported here.
Courson et al. showed that endoscopic techniques
for the treatment of frontal and frontoethmoid mucoceles
have similar recurrence rates compared to open techniques with indications for external approaches including
unfavorable anatomy, lateral disease, and scarring.
Strong evidence supported surgical treatment of frontal
mucoceles with results from endoscopic and open
approaches comparable.8 Crozier et al. demonstrated
resolution of CSF leaks after repair via frontal trephination, with no recurrence at an average of 37 months.19
Walgama et al. had recurrence of inverted papilloma in
1/5 patients; however, this was not procedure related.
There was no mention of frontal sinus patency.7 Seiden
and el Hefny achieved complete excision of an osteoma
and showed full resolution at the 8-month follow-up.12
Sautter et al. showed complete removal of inverted papilloma in one patient, with no recurrence at 16.8 months
and no mention of frontal sinus patency.15 Yoon et al.
had recurrence of inverted papilloma in 1/5 patients;
however, this was not procedure related. There was no
mention of frontal sinus patency.17 Cohen et al. showed
no recurrence of inverted papilloma in one patient at 14
months.16 Seiberling et al. demonstrated complete excision of osteoma in 10 patients with no recurrence. There
was no mention of frontal sinus patency.11 Zacharek
et al. had 1/13 patients requiring revision surgery, with
Patel et al.: Applications of Frontal Trephination
TABLE IV.
Outcomes of Trephination Approach.
First Author, Year
Patients
Type of Study/EBM Level
Outcome
Crozier, 201319
4
RR/level 4
Full resolution of CSF leaks, no recurrence at 37
months follow-up
Walgama, 20127
5
Systematic review/level 3
Recurrence of inverted papilloma in 1/5 patients at
average 17.5 months follow-up, however not
procedure related
Chaaban, 201223
1
Prospective/level 3
Seiberling, 20092
151
RR/level 4
Hahn, 20096
20
RR/level 4
Full resolution of the defect with 100% endoscopic
patency at 17 months follow-up
Total of 149 bilateral and 39 unilateral with 151
patients showing endoscopic patency at an
average 25.5 months
8/14 required revision surgery with 15/20 patients
improved at 12.8 months
Seiberling, 200911
10
RR/level 4
Complete excision of osteoma, no recurrence
Yoon, 200917
5
RR/level 4
Recurrence of inverted papilloma in 1/5 patients,
however not procedure related
Maeso, 20093
Cho, 200825
1
1
RR/level 4
RR/level 4
Full resolution of disease at 36 months
Full endoscopic patency at 5 months
Cohen, 200716
13
RR/level 4
12/13 patients free of disease at follow-up of 14.2
months with patency in 23/24
Cohen, 200716
1
RR/level 4
Sautter, 200715
1
RR/level 4
Zacharek, 20064
13
RR/level 4
Complete excision of inverted papilloma, no
recurrence at 14 months
Complete excision of inverted papilloma, no
recurrence at 16.8 months
1/13 patients requiring revision surgery, 29 months
average follow-up
Batra, 20055
5
RR/level 4
19/22 patients with endoscopic patency, 16.2 months
average follow-up
Benoit, 200129
40
RR/level 4
Complete patency in 79%, symptom improvement in
78%
Gallagher, 19999
16
RR/level 4
Seiden, 199512
1
RR/level 4
Complete patency in 15/16 patients at 3.8 months
follow-up
Complete excision of an osteoma with full resolution
at 8 months follow-up
Gerber, 199327
2
RR/level 4
Full resolution of disease at 4 months
CSF 5 cerebrospinal fluid; EBM 5 evidence-based medicine; RR 5 retrospective review.
all others showing complete resolution of symptoms at a
follow-up of 29.9 months.4 Chaaban et al. had no complications with a posterior table fracture repair and showed
full resolution of the defect with 100% endoscopic patency at 17 months.23 Batra et al. showed 19/22 (86%)
with endoscopic patency at a 16.2-month average followup.5 Maeso et al. demonstrated no recurrence of symptoms postmanagement of frontal sinus type 4 cell disease
at 3 years.3 Gallagher and Gross show complete patency
of the frontonasal recess in 15/16 patients at 3.8
months.9 Gerber et al. show full resolution of symptoms
in their two patients at an average of 4 months.27 Hahn
et al. showed a total of 8/14 (57.1%) of all trephines during the study period requiring revision surgery, with 15/
20 (80%) patients showing improvement at 12.8
months.6 Seiberling et al. had a total of 149 bilateral
and 39 unilateral, with 151 (92%) patients showing
endoscopic patency of the frontal sinus at an average
25.5 months.2 Cohen and Wang demonstrated 12/13
(92%) patients to be free of disease at a follow-up of 14.2
months, with 23/24 (96%) of frontal recesses deemed
Laryngoscope 125: September 2015
patent.16 Cho et al. demonstrated full endoscopic patency at 5 months after removal of a frontal sinus mucocele.25 Benoit and Duncavage reported on combined
external and endoscopic frontal sinusotomy with stent
placement in 40 patients, with overall patency of the
nasofrontal duct and subjective patient improvement
rate at 79% and 78%, respectively.29
Complications (EBM level 4). Both inflammatory
and noninflammatory related studies were examined for
complications related to the frontal sinus trephination
procedure (Table V). All studies examined were of level 4
evidence. Seiberling et al. had the largest series with
188 patients, and showed multiple complications, the
most frequently encountered being periorbital cellulitis
and facial cellulitis in 4/188 patients (2.1%). This study
also showed asystole, CSF leak, proptosis, and bleeding
in 1/188 patients each (0.5%).2 Batra et al. showed facial
cellulitis or periorbital cellulitis in 1/22 patients (4.5%).5
Walgama et al. reported a CSF leak in 1/5 patients.7
Gallagher et al. had a CSF leak in 1/16 (6.3%) of
patients. This study also showed a complication of skin
Patel et al.: Applications of Frontal Trephination
2049
TABLE V.
Complications.
Complication
Patients
Total Patients
Author
1/22, 4/188
4.5% 2.1%
Batra, 20055; Seiberling, 20092
1/188, 1/5, 1/16
0.5%, 20.0%, 6.3%
Asystole
1/188
0.5%
Seiberling, 20092; Walgama, 20127;
Gallagher, 19999
Seiberling, 20092
Proptosis
1/188
0.5%
Seiberling, 20092
Bleeding
Superior oblique palsy/trochlea damage
1/188
1/1
0.5%
NA
Seiberling, 20092
Bartley, 201230
Retro-orbital fluid dissection
1/1
NA
Andrews, 201331
Burns
2/16
12.5%
Gallagher, 19999
Facial cellulitis/periorbital cellulitis
Cerebrospinal fluid leak
NA 5 not available.
burns from the procedure in 2/16 (12.5%).9 Bartley
reported a case of superior oblique palsy/trochlear injury
in one patient.30 Similarly, Andrews et al. reported a
case of retro-orbital fluid collection in one patient.31
Safety (EBM level 4). Several studies have
reviewed the safety of frontal sinus trephination given
the risk of injury to critical structures. Traditionally,
there has been a paucity of literature describing the
ideal location for trephination; however, recent studies
have analyzed this further. Lee et al. reviewed computerized tomography (CT) of 200 patients. They were able
to show the mean depth of frontal sinus at 5 mm, 10
mm, and 15 mm from midline to be 11.26 mm (range, 0–
21.8 mm), 11.45 mm (range, 0–23.1 mm), and 11.48 mm
(range, 0–28.1 mm), respectively.32 This study showed
no statistical difference in frontal sinus depth measurements performed at 5 mm, 10 mm, and 15 mm from a
midline passing through the crista galli. They concluded
that the sinus can be successfully trephined at 5 mm, 10
mm, or 15 mm in a majority of patients.32 Piltcher et al.
reviewed 69 CT scans similarly at measurements of
5 mm, 10 mm, and 15 mm from midline. Men presented
a frontal sinus significantly larger in the distances of
5 mm and 10 mm when compared to women, but there
was no statistical difference in the depth of the sinus at
15 mm.33 The frontal sinus depth measured at 5 mm of
the midline was significantly larger than that at 10 and
15 mm, just as the measure at 10 mm was significantly
Fig. 1. Intraoperative images using
the three-dimensional computerized
image guidance system. The bottom
right panel shows the intraoperative
endoscopic image with the probe
into the fistula. The computed
tomography (CT) images show the
axial, coronal, and sagittal correlates
of the tip if the probe. The probe
has been inserted into the fistula
after performance of the frontal
trephination. The CT images also
show the preoperative view of the
fistula in the three dimensions. The
fistula between the right frontal
sinus and subcutaneous area is
denoted by the white broken line,
and the metal plate is clearly visualized (intersecting lines).
Laryngoscope 125: September 2015
2050
Patel et al.: Applications of Frontal Trephination
Fig. 2. Intraoperative images of the
surgical approach and repair. (A) A
right brow incision has been performed after mapping the frontal
sinus and the area of the fistula with
the intraoperative image guidance.
The subcutaneous tissue has been
carefully retracted, protecting the
surrounding neurovascular pedicles
medially. (B) Using a pediatric 30
endoscope, the fistula (arrow) is
visualized at the superolateral part
of the right frontal sinus. (C) The
mucosal edges of the fistula and the
fistula tract have been removed to
prepare for the multilayered repair.
The metallic plate is clear visualized
(arrow). (D) The multilayered repair
has been completed, with the final
layer utilizing a free nasal mucosal
graft. The frontal ostium area was
debrided of the bone wax (not
shown here) and the sinus was not
obliterated.
higher when compared to that at 15 mm (12.22 vs.
11.78 mm, 12.22 mm vs. 10.78 mm, 11.78 mm vs.
10.78 mm).33 In their study, the sinus depth when measured at 5, 10, and 15 mm away from the midline showed
statistically significant differences, demonstrating that
the closer the proximity to the midline, the deeper it
was. They however concluded that the usual distance of
10 mm from the midline proved to add more advantages
for trephination when the risk of crossed trephination at
the 5-mm mark and the risk of sinus hypotrophy at
15 mm are considered.33 Ponde et al. reviewed 98 CT
scans for dimensions and volume. The average anteroposterior diameter was 12.01 mm in males and
10.16 mm in females. The average transverse diameter
was 56.53 mm in males and 51.05 mm in females. The
average sagittal diameter was 31.72 mm in males and
28.57 mm in females.34 The average volume was
129.99 mm3 in males and 80.26 mm3 in females. They
concluded that knowledge of the anatomic variations of
the frontal sinus is important with surgical approaches
through the supraciliary arch to avoid complications.34
Case
A 58-year-old male underwent a revision right frontotemporal craniotomy for a resection of an anterior
Laryngoscope 125: September 2015
cranial fossa meningioma. During surgery, an inadvertent breach of the right frontal sinus at the junction of
the lateral roof and posterior wall was created. Intraoperative repair with absorbable Gelfoam was attempted,
but in the postoperative period, the patient noted the
right forehead scalp to inflate with air upon noseblowing and use of continuous positive airway pressure
(CPAP). Initially, the patient was observed for spontaneous resolution; however, after 7 months, his symptoms
continued. Further investigation with CT and magnetic
resonance imaging (MRI) showed a subcutaneous aircommunicating fistula extending from the cranioplasty
site to the far superolateral frontal table (Fig. 1). A
small bony defect was noted in the superolateral aspect
of the right frontal sinus, with air below the craniotomy
plate extending inferolaterally in the right scalp. Further intervention was indicated, as there was risk for
dural contamination from the sinus contents. The
patient was referred to the endoscopic skull base surgeon for evaluation. After careful consideration, endoscopic frontal trephination and repair was deemed
feasible.
Image guidance was used for preoperative planning.
The patient was noted to have a hyperpneumatized frontal sinus reaching far lateral, and as a result, a frontal
trephination was planned lateral to the supraorbital
Patel et al.: Applications of Frontal Trephination
2051
Fig. 3. Magnetic resonance imaging
performed 6 months later for surveillance of the frontal meningioma.
Both the coronal (left) and axial
(right) images using T1-weighted
sequences
with
gadolinium
enhancement show the subcutaneous fistula to be fully healed. The
right frontal recess shows no mucosal thickening and is healthily aerated. (B) On the left is the patient
performing a Valsalva maneuver; no
frontal subcutaneous air is noted.
On the right is a close-up view of
the brow showing that the incision
is well healed and well concealed.
notch. Image guidance was used to plan the approach
and avoid intracranial breach. A 1-cm brow incision was
created, with the scalpel beveled to preserve the brow
trichia. The supraorbital and supratrochlear nerves
were identified and retracted away. Next, a cutting burr
was used to enter into the frontal sinus, and a 1 cm 3
1 cm opening into the anterior frontal table was created
with the use of Kerrison rongeurs and the diamond burr.
The pediatric 0 , 30 , and 45 endoscopes were inserted
through this minitrephination to visualize the area of
the fistula (Figs. 1 and 2). The fistula was then resected,
carefully avoiding any dural injury. Next, a multilayered, air-tight closure was performed (Fig. 2) using acellular tissue matrix (Alloderm), bovine collagen matrix
(DuraGen), and a free mucosal graft in layers. DuraGen
was first used to plug a high defect in the undersurface
of the metallic plate used in the initial craniotomy
repair. Alloderm was then placed in the subcutaneous
plane over the superficial aspect of the plate and was
tucked under edges of bony recess. Finally, a free mucosal graft harvested from the left nasal septum was
placed over the frontal sinus defect to repair the mucosa
as an overlay layer. The area of the frontal recess was
found partially plugged with bone wax from previous
repair. This was carefully removed, making sure that
the mucosa in the frontal recess was not injured at all
(to prevent problems with iatrogenic frontal recess
obstruction). No intraoperative complications were noted
and the patient was discharged home the same day. He
remains symptom free at 18 months of follow-up and
uses CPAP without problems. The trephine incision
healed as a well-camouflaged scar. MRI performed 9
months postoperatively for tumor surveillance showed
Laryngoscope 125: September 2015
2052
full resolution of the fistulous tract and no recurrence of
tumor (Fig. 3).
DISCUSSION
Evidence of frontal trephination approaches date
back as early as prehistoric times. Two specimens demonstrating the trephination approach for frontal sinus
pathology were collected in the second decade of this
century in Peru dating back approximately 600 years.35
The approach was first described in the literature by
Runge in 1750, and Hutchinson further described the
procedure in 1939 as a puncture technique into the frontal sinus.9,10 Since that time period, this procedure has
undergone considerable advancement.10,36
In 1991, Hoffman and May described an “above and
below” approach to the frontal sinus using the trephine
porthole.37 Subsequent studies have been published
reviewing patients who underwent a combined trephination with frontal sinusotomy for complex frontal sinus
pathology.5–8 However, due to difficulties with endoscopic
access to the lateral-most extent of the sinus, combined
with the need for preservation of the frontal sinus outflow tract and minimization of postoperative scarring,
there has been continued evolution of technique and
instrumentation for access to this area.1–5,10,15,36
Within the era of endoscopic sinus surgery, frontal
sinus trephination has remained the most routinely utilized of all external procedures.1–5,36 Frontal trephination allows surgery to be performed through a small and
well-camouflaged external incision without disruption of
the frontal sinus outflow tract.36,37 Although transnasal
endoscopic approaches can be attempted for pathology in
Patel et al.: Applications of Frontal Trephination
the lateral frontal sinus, the anatomy is often not conducive to such approach in addition to the longer operative
time and surgical skill required. With a transnasal
approach, there is always risk of permanent scarring of
the frontal recess necessitating revision surgery in the
future.36
In challenging cases and/or revision cases, however,
the trephine can be used as an adjunct to an endoscopic
approach through an above and below visualization and
dissection technique.5–8 To this day, frontal sinus trephination remains a simple, direct, and cosmetically excellent alternative. The exit point for the supraorbital
neurovascular pedicle and awareness of the supratrochlear nerve bundle is important to ensure safe dissection.19,37,38 It affords minimal morbidity when compared
to other external approaches and allows for preservation
of physiologic sinus function.
CONCLUSION
Frontal sinus trephination should not be regarded
as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. As
our case report and systematic literature review suggests, indications for noninflammatory use in the contemporary era include trauma, tumor, and repair of
skull base defects resulting in CSF leak and pneumocephalus. Furthermore, frontal trephination continues to
have a pivotal role in treatment of inflammatory disease.
The approach may be used as a supplement to the transnasal endoscopic approach (above and below approach)
or purely through a trephination approach. Such an
approach provides adequate access for both endoscopic
visualization and instrumentation into the far lateral
and superior areas of the frontal sinus.
BIBLIOGRAPHY
1. Schneider JS, Archilla A, Duncavage JA. Five ‘nontraditional’ techniques
for use in patients with recalcitrant sinusitis. Curr Opin Otolaryngol
Head Neck Surg 2013;21:39–44.
2. Seiberling K, Jardeleza C, Wormald PJ. Minitrephination of the frontal
sinus: indications and uses in today’s era of sinus surgery. Am J Rhinol
Allergy 2009;23:229–231.
3. Maeso PA, Deal RT, Kountakis SE. Combined endoscopic and minitrephination techniques in the surgical management of frontal sinus type IV
cell disease. Am J Otolaryngol 2009;30:337–339.
4. Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: A
minimally invasive approach for hard-to-reach frontal sinus disease.
Otolaryngol Head Neck Surg 2006;135:518–522.
5. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and
endoscopic frontal sinusotomy for management of complex frontal sinus
pathology. Am J Rhinol 2005;19:435–441.
6. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for
external frontal sinus procedures for inflammatory sinus disease. Am J
Rhinol Allergy 2009;23:342–347.
7. Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus
inverted papilloma: a systematic review. Laryngoscope 2012;122:1205–
1209.
8. Courson AM, Stankiewicz JA, Lal D. Contemporary management of frontal
sinus mucoceles: a meta-analysis. Laryngoscope 2014;124:378–386.
9. Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinol 1999;13:289–293.
Laryngoscope 125: September 2015
10. Jacobs JB. 100 years of frontal sinus surgery. Laryngoscope 1997;107(11 pt
2):1–36.
11. Seiberling K, Floreani S, Robinson S, Wormald PJ. Endoscopic management of frontal sinus osteomas revisited. Am J Rhinol Allergy 2009;23:
331–336.
12. Seiden AM, el Hefny YI. Endoscopic trephination for the removal of frontal sinus osteoma. Otolaryngol Head Neck Surg 1995;112:607–611.
13. Busch R. Frontal sinus osteoma: complete removal via endoscopic sinus
surgery and frontal sinus trephination. Am J Rhinol 1992;6:139–143.
14. Senior BA, Lanza DC. Benign lesions of the frontal sinus. Otolaryngol
Clin North Am 2001;34:253–267.
15. Sautter NB, Citardi MJ, Batra PS. Minimally invasive resection of frontal
recess/sinus inverted papilloma. Am J Otolaryngol 2007;28:221–224.
16. Cohen AN, Wang MB. Minitrephination as an adjunctive measure in the
endoscopic management of complex frontal sinus disease. Am J Rhinol
2007;21:629–636.
17. Yoon BN, Batra PS, Citardi MJ, Roh HJ. Frontal sinus inverted papilloma:
surgical strategy based on the site of attachment. Am J Rhinol Allergy
2009;23:337–341.
18. Kabil MS, Shahinian HK. The endoscopic supraorbital approach to tumors
of the middle cranial base. Surg Neurol 2006;66:396–401; discussion
401.
19. Crozier DL, Hwang PH, Goyal P. The endoscopic-assisted trephination
approach for repair of frontal sinus cerebrospinal fluid leaks. Laryngoscope 2013;123:321–325.
20. Purkey MT, Woodworth BA, Hahn S, Palmer JN, Chiu AG. Endoscopic
repair of supraorbital ethmoid cerebrospinal fluid leaks. ORL J Otorhinolaryngol Relat Spec 2009;71:93–98.
21. Das PT, Balasubramanian D. External frontal sinusotomy and endoscopic
repair of cerebrospinal fluid fistula in the posterior wall: preliminary
report of a new technique. J Laryngol Otol 2011;125:802–806.
22. Jatana KR, Ryoo C, Skomorowski M, Butler N, Kang DR. Minimally invasive repair of an isolated posterior table frontal sinus fracture in a pediatric patient. Otolaryngol Head Neck Surg 2008;138:809–811.
23. Chaaban MR, Conger B, Riley KO, Woodworth BA. Transnasal endoscopic
repair of posterior table fractures. Otolaryngol Head Neck Surg 2012;
147:1142–1147.
24. Koento T. Current advances in sinus preservation for the management of
frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg 2012;20:
274–279.
25. Cho SH, Lee YS, Jeong JH, Kim KR. Endoscopic above and below
approach with frontal septotomy in a patient with frontal mucocele: a
contralateral bypass drainage procedure through the frontal septum.
Am J Otolaryngol 2010;31:141–143.
26. Fry TL, Biggers WP, Fischer ND. Frontal sinus trephination: a new technique for office procedure. Laryngoscope 1980;90(5 pt 1):838–841.
27. Gerber ME, Myer CM III, Prenger EC. Transcutaneous frontal sinus
trephination with endoscopic visualization of the nasofrontal communication. Am J Otolaryngol 1993;14:55–59.
28. McIntosh DL, Mahadevan M. Frontal sinus mini-trephination for acute
sinusitis complicated by intracranial infection. Int J Pediatr Otorhinolaryngol 2007;71:1573–1577.
29. Benoit CM, Duncavage JA. Combined external and endoscopic frontal
sinusotomy with stent placement: a retrospective review. Laryngoscope
2001;111:1246–1249.
30. Bartley J, Eagleton N, Rosser P, Al-Ali S. Superior oblique muscle palsy
after frontal sinus mini-trephine. Am J Otolaryngol 2012;33:181–183.
31. Andrews JN, Lopez MA, Weitzel EK. Case report of intraoperative retroorbital fluid dissection after frontal mini-trephine placement. Laryngoscope 2013;123:2969–2971.
32. Lee AS, Schaitkin BM, Gillman GS. Evaluating the safety of frontal sinus
trephination. Laryngoscope 2010;120:639–642.
33. Piltcher OB, Antunes M, Monteiro F, Schweiger C, Schatkin B. Is there a
reason for performing frontal sinus trephination at 1 cm from midline?
A tomographic study. Braz J Otorhinolaryngol 2006;72:505–507.
34. Ponde JM, Metzger P, Amaral G, Machado M, Prandini M. Anatomic variations of the frontal sinus. Minim Invasive Neurosurg 2003;46:29–32.
35. Canalis RF, Cabieses F, Hemenway WG, Aragon R. Prehistoric trephination of the frontal sinus. Ann Otol Rhinol Laryngol 1981;90(2 pt 1):186–
189.
36. Murr AH. Contemporary indications for external approaches to the paranasal sinuses. Otolaryngol Clin North Am 2004;37:423–434.
37. Hoffmann DF, May M. Endoscopic frontal sinus surgery: frontal trephine
permits a two-sided approach. Oper Tech Otolaryngol Head Neck Surg
1991;2:257–261.
38. Harvey RJ, Gallagher RM, Sacks R. Extended endoscopic techniques for
sinonasal resections. Otolaryngol Clin North Am 2010;43:613–638.
Patel et al.: Applications of Frontal Trephination
2053